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Wheeless' Textbook of Orthopaedics
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Distal Biceps Tendon Rupture



- Two Incision Approach (Boyd and Anderson)
    - advantages:
            - two-incision technique to limits the anterior dissection and therefore may limit pain;
            - may reduce injury to the radial nerve, which can occur w/ a one incision technique that incorporates drill holes thru the radius;
            - rerupture is uncommon;
            - following surgical repair, most pts achieve nearly normal isometric strength, & many are capable of relatively normal endurance;
            - allows stronger fixation than the one incision technique:
            - ref: Surgical Repair of Distal Biceps Tendon Ruptures. A Biomechanical Comparison of Two Techniques
    - disadvantages:
            - supinator may have to be detached from the ulna, which would further weaken supination strength;
            - synostosis (between the radius and ulna) may occur from the following:
                    - from stripping of the aconeus andsupinator muscles;
                    - from having the posterior tunnel directly over the periosteal surface of the ulna;
                    - from disruption of the proximal interosseous membrane and, with subsequent hematoma formation,
                    - from bone dust debris from burring of the radial tuberosity;
    - technique:
            - proximal incision:
                    - 3-cm transverse incision is made over the distal biceps tendon sheath;
                    - care is taken to avoid injury to the lateral antebrachial cutaneous nerve;
                    - enter the tendon sheath and identify the tendon stump and then retracted into the wound;
                    - insert a core tendon suture through the end of the tendon;
            - distal incision:
                    - the forearm is maximally pronated;
                    - a curved hemostat is passed through the biceps tendon sheath and is passed down between the radius and the ulna;
                    - it is then passed thru the common extensor muscles until it can be palpated underneath the subcutaneous tissues;
                            - muscle-splitting approach avoids subperiosteal exposure of the ulna in an attempt to lessen the likelihood of a proximal synostosis;
                    - tip of the hemostat is then palpated on the dorsal surface of the forearm to locate the position of the posterior incision;
                            - it is important that the curved hemostat not be passed along the ulnar periosteal surface, so as to avoid a radial-ulnar synostosis;
                    - 4-cm muscle-splitting incision is made and taken down to the radial tuberosity;
                    - an incision is then made, which allows exposure of the radial tuberosity;
                            - with acute repairs finding the radial tuberosity is usually possible, but the tuberosity is often
                                    obscured with delayed repairs;
                    - alternatively use a posterolateral approach to the elbow;
            - anchor the tendon:
                    - small osteotome is used to create a concavity in the tuberosity;
                    - drill holes are made through the radial tuberosity inorder to allow anchoring of the tendon;
                    - frequently irrigate the wound to remove all bone dust (to avoid synostosi);
                    - pass sutures thru the biceps using the weave of choice (Bunnel, Krachow ect...);
                    - the biceps is then retrieved thru the distal incision;
                    - sutures are then passed thru the tuberosity drill holes and is tied down;


- Outcomes:
    - in the report EW. Kelly et al (J Bone Joint Surg [Am] 82-A: 1575-81, 2000), the authors report on a
            retrospective review of the results of 78 consecutive anatomical repairs of the distal biceps tendon
            performed through a muscle-splitting 2 incision technique between 1981 and 1998;
            - 4 of the 8 required a graft to restore length;
            - complications developed after 23 (31 %) of the 74 repairs;
                  - complications included 5 sensory nerve paresthesias (3 lateral antebrachial cutaneous and 2 superficial radial nerve paresthesias) in 5 patients;
                  - 6 patients complained of persistent anterior elbow pain;
                  - heterotopic ossification that did not limit forearm rotation developed in four patients, a
                          superficial wound infection developed in three, one tendon reruptured, three patients lost
                          forearm rotation, and reflex sympathetic dystrophy developed in one patient.
                  - complications developed after ten (24 %) of the 41 acute repairs (performed fewer than ten days after the injury),
                          6 (38 %) of the sixteen subacute repairs (performed ten to 21 days after the injury), and seven (41 %) of the
                          17 delayed repairs (performed more than 21 days after the injury).
            - the authors note that most of the morbidity from repair of the distal biceps tendon can be attributed primarily to
                  a delay in the timing of the repair and secondarily to an extensive anterior exposure;
            - the authors note that radioulnar synostosis is rare following the muscle-splitting modification of the two-incision technique;
            - they also noted only one temporary PIN palsy;




Proximal radioulnar synostosis after repair of distal biceps brachi rupture by the two-incision technique. Report of four cases.
      JM Failla et al. CORR. Vol 253.. p 133. 1990.

Rupture of the distal insertion of the biceps brachi tendon.

Rupture of the distal tendon of the biceps brachi. A biomechanical study.

Rupture of the distal tendon of the biceps brachi, Operative versus non-operative treatment.

Distal biceps brachii tendon avulsion: a simplified method of operative repair.
      DS Louis et al.   Am J. Sports Med. Vol 14. 1986. p 234.

Partial rupture of the distal biceps tendon.

Repair of the distal biceps tendon using suture anchors and an anterior

Distal biceps brachii repair. Results in dominant and nondominant extremities.

A method for reinsertion of the distal biceps brachii tendon.
      HB Boyd et al.   JBJS. 43-A. 1961. p 1041.

Rupture of the distal biceps tendon: biomechanical assessment of different treatment options.
      WH Norman.   CORR. Vol 193. 1985. p 189.

Clinical, Functional, and Radiographic Assessments of the Conventional and Modified Boyd-Anderson Surgical Procedures for Repair of Distal Biceps Tendon Ruptures N
      Patrick D'Arco MEd, ATC.   American Journal of Sports Medicine Vol 26 No 2 March - April 1998

Radioulnar synostosis after the two-incision biceps repair: A standardized treatment protocol.

Permanent posterior interosseous nerve palsy following a two-incision distal biceps tendon repair.







Original Text by Clifford R. Wheeless, III, MD.